Fourth phase of the NHS response to COVID-19

Headline points and the NHS Confederation's view on guidance on the fourth phase of the NHS COVID-19 response.

26 March 2021

On 25 March, NHS England and NHS Improvement (NHSEI) chief executive Sir Simon Stevens and chief operating officer Amanda Pritchard wrote to NHS organisations to outline the fourth phase of the response to COVID-19 and the NHS’s priorities from 1 April 2021. The focus for this phase is on recovering NHS services through enhanced system working. Implementation guidance has also been published.

Since the phase 3 planning guidance was published in July last year, the NHS Confederation has been facilitating conversations between our members and NHSEI leaders on key issues, as part of our NHS Reset campaign. In February the campaign entered a new phase, looking beyond the pandemic to recovery of both staff and services, in the context of ongoing COVID-19 pressures.

Various reports, briefings and thought-leadership pieces have been published as part of this ongoing campaign.

This briefing sets out our view on the guidance and how we plan to support members, and summarises some of the key issues within the guidance.

Key points

  • The priority given to workforce wellbeing and recovery within the guidance, as well as the commitment to invest in and expand mental health hubs, is very welcome. However, the guidance does not go far enough in supporting the workforce, and the ambitious elective recovery targets may undermine these initiatives.
  • The guidance’s phased approach to restoring services is welcome. However, the use of incentives must not disadvantage areas that happen to have been more greatly impacted by COVID-19, nor systems that are in their infancy.
  • While we broadly support the prioritisation of restoring elective work and the focus on clinical prioritisation in the guidance, there needs to be clear, consistent and honest communication to the public about what they can expect from NHS staff and organisations and how their care will be managed. Our members need access to capital now to start addressing the elective backlog.
  • We are glad to see that the guidance is underpinned by system working, but the ongoing role of clinical commissioning groups (CCGs) is overlooked and there must be an acknowledgement that not all systems are at the same stage of development. Our ICS members have concerns about having to take on wider primary care commissioning responsibilities from NHSEI once they become statutory and some will also find it challenging to align their boundaries with upper-tier local authorities by April 2022.
  • We welcome the commitment to tackle health inequalities. The focus at integrated care system (ICS) level should be on empowering local communities and primary care networks (PCNs) to work with residents and address their priorities.
  • As outlined in our recent letter to the Chancellor, we expect and need the government to provide clarity on how the direct COVID-19 costs for the second half of the year will be funded.

NHS Confederation viewpoint

Based on intensive listening to members in every part of the system over the past months, weeks and days, the NHS Confederation’s reaction to the phase 4 planning guidance can be summarised within the following themes:


The priority given to workforce wellbeing and recovery within the guidance, as well as the commitment to invest in and expand mental health hubs, is welcome.

However, the guidance does not go far enough to support a workforce which is fragile and exhausted after a year of a pandemic, and which started behind many other health systems in terms of staff capacity. The guidance rightly encourages all staff to take time off to recover, but this is a challenge among the smaller organisations in primary care such as PCNs, where there may only be one person in each role.

The guidance sets out some challenging expectations of progress on workforce ambitions for 2021/22, which may not account for the disruption and challenges faced during the pandemic that have set staff back. Moreover, the ambitious elective recovery targets outlined will create further pressures.

To make a significant difference to staff experience we will need to enable employers to go further around workforce growth, deploy new roles, and create capacity to train and extend the scope of existing roles. The Health Foundation identified that £600 million would be needed in 2021-22 to support training of additional healthcare professionals.

The NHS Staff Survey revealed that fewer than 40 per cent of NHS staff feel their organisation has sufficient people to enable them to do their job. Addressing workload pressures and investing in workforce growth across the whole system are critical areas for focus that will go some way towards delivering workplaces that can sustain improvements in staff experience, including going further on flexible working.

The additional funding cited is welcomed, but it is unclear how much of the £1.5 billion outlined in the guidance will be allocated to workforce development, alongside elective recovery and mental health services. Our recent report highlighted that to attract and retain staff in the long term, the NHS will need a fully funded, long-term workforce plan addressing training and vacancy issues, as well as a sustainable, funded and modern total reward package.

System working

The emphasis on system working in the guidance is welcome and many aspects will come as no surprise to ICS chairs and leaders. The continued focus on system-based approaches to funding and planning, as well as the continuation of block contract payments, are sensible. The guidance rightly highlights the importance of looking after our best asset – our people. We also welcome the opportunity for ICSs to develop their own set of local health and care priorities that reflect the needs of their population.

The guidance recognises the important work required to prepare ICSs for taking on statutory responsibilities. This includes ensuring they have the necessary functions, leadership and governance. It is important to note that not all systems are at the same stage of development; while some have progressed quickly, others will need significant support to be ready for statutory status. For example, some systems will have concerns about being unprepared to take on the commissioning of wider primary care services from NHSEI immediately upon becoming statutory (as it states in the implementation guidance).

Perhaps the most contentious issue for certain systems will be what the accompanying guidance states on ICS boundaries, which ‘will align with upper-tier local authority boundaries by April 2022, unless otherwise agreed by exception.’ While it is welcome that there is now a clear position on this issue and that exceptions will be possible, any boundary changes will be a difficult and time-consuming process for the affected systems. This makes the April 2022 target more difficult and systems that are set to be affected by boundary changes may well need additional support to ensure they are not significantly set back.

While the guidance talks about ICSs moving to a statutory footing by April 2022, it is disappointing that the guidance does not appear to acknowledge that 2021 is a transition year for CCGs, and that the future success of system working will rely on their strong legacy and the preparation many are already involved in, not to mention the work being done by those CCG leaders who are already also leading ICSs.

CCGs are still the bedrock of the NHS commissioning framework and are accountable for the planning and delivery of services until April 2022, holding two-thirds of the total NHS budget. Their role should not be undermined while they play an important role in the post-pandemic recovery, restart of services, and in tackling the increased health inequalities that have emerged.

Elective recovery alongside ongoing COVID-19 pressures

We welcome the focus on prioritisation of elective work, including clinically-led reviews to prioritise patients most in need and the important revalidation of waiting lists. Given the many variables, it is also good to see that NHSEI will not be penalising trusts for not meeting elective targets.

There is a collective ambition to recover elective services in the interest of patients and the service, so it is right that trajectories are set ambitiously. However, it is important to recognise that, although phased, these targets are at the top end of what is achievable for a service under strain and that, depending on a range of variables, systems will have different challenges in meeting them.

However, it is crucial that both the government and NHSEI provide clear messaging that the elective backlog will not be resolved in 12 months, as is clarity that waiting times will be managed differently as the NHS recovers from the pandemic. Our recent report revealed that the waiting list could exceed 5.6 million by the end of the year, and Nuffield Trust research shows that the UK ‘started behind’ many other countries when the pandemic hit, with higher occupancy rates, lower staff capacity and fewer capital assets.

We are concerned that the financial incentives to elective recovery may disproportionately benefit areas that have lower COVID-19 levels and better estates, which would further exacerbate disparities. The baseline accounting for impacts during the pandemic will not be enough to ensure the Elective Recovery Fund is not used as a blunt instrument. We are also concerned that financial incentives could also be used to reward ‘easy wins’ rather than helping those patients with most clinical need.

Our members are concerned about a difficult winter ahead, with the likely flu programme on top of a revaccination programme. While the guidance acknowledges this possibility, there is no recognition of how this would affect the proposed targets. In order to plan, commission and deliver services next winter, members tell us they need access to capital now to start addressing the elective backlog; particularly for new equipment and to improve estates that are unsuitable for long term COVID-19-related infection prevention and control measures This needs to be available now and over the summer to enable preparation for a potential autumn COVID-19 wave.

The pandemic has highlighted the devastating inequalities that exist and there is a risk that a drive to reduce waiting lists will prioritise volume of activity over need. Our members have demonstrated their desire and skill in reaching out to disadvantaged communities to deliver fair access to the vaccination programme. This same enthusiasm should be both encouraged and supported in the elective recovery, with a clear directive for dialogue between primary and secondary care to ensure patients are prioritised on risk and not self-efficacy.

Mental health

We welcome the acknowledgement that demand on mental health services is increasing. It is positive to see that CCGs must continue to meet the Mental Health Investment Standard (MHIS) and that the £500 million of additional Spending Review funding cannot be used to meet the MHIS or to cover direct COVID-19 costs, such as PPE. The guidance confirms that the £500 million must be used to help with progress against goals in the NHS Long Term Plan and aid recovery of services from COVID-19. However, the important detail on how it should be spent has still not been confirmed. This detail needs to be communicated as soon as possible so the sector can plan for the next financial year.

We are disappointed that there is no mention of the voluntary, community and social enterprise (VCSE) sectors in the guidance, as these organisations will play a vital role in supporting the NHS to help meet the additional demand and reduce inequalities that have been exacerbated by the pandemic. We hope that some of the additional £500 million will be to support VCSE organisations.

Health inequalities

When the government’s White Paper passes into law, ICSs will have a statutory duty to address health inequalities. The dedicated section on addressing health inequalities at system level in the accompanying implementation guidance is well received.

As a part of this, primary care will play an important role in improving health inequalities, for instance through improving accuracy of the GP learning disability register with a focus on patients from ethnic minority backgrounds.

We agree with the guidance on increasing use of non-admitted pathways, including virtual wards, as escalated throughout the pandemic, as a useful tool in delivering care in the safest setting and overcoming capacity challenges.

However, we would be keen to see any advances properly evaluated for impact. For instance, investigating what has worked well, what did not and why, from the standpoint of equity and digital inclusion, which needs to be considered before new technologies are embedded. As a recent study found, there is a real divide, with nearly a quarter of the population not having access to broadband internet.

Transformation opportunity

We welcome the opportunity for this moment not just to be a point to start a recovery but also for a rethink of how we deliver services. For instance, emphasising clinical-led (rather than just operational) reviews of care pathways, and the recognition of interdependence between primary and secondary care in achieving recovery of elective services.

It is important to highlight systems’ achievements, such as the significant reductions in long stays, as quoted in the guidance, but there also needs to be consideration for maintaining capacity to respond to future outbreaks.

Primary care has played a transformational role in the COVID-19 response and the vaccination programme, enabled by PCNs. The recognition for this is welcomed. The sector has found innovative ways of using their workforce via the Additional Role Reimbursement Scheme (ARRS) and collaboration across practices and ‘networks of networks’ at place-level, which are lessons for the system plan.

Furthermore, as recognised in the guidance, waiting lists are a real opportunity for collaboration, with an expanded role of primary care insight and leadership being critical to success. However, there is little detail on the specifics of how primary care will be involved and resourced to deliver.

For primary care to continue to deliver the COVID-19 response, the vaccination programme, and its foundational role in delivering this guidance, it will require further capacity, such as the extension of the specific clinical director funding, to play its strategic role. The success of primary care’s response to COVID-19 and the vaccination was enabled by the increased investment in PCNs, which will be required as we look ahead to preparing for revaccination later in the year.

What the guidance covers


  • Around £9.6 billion of funding was already confirmed to cover COVID-19 costs for the first half of the year. This refers to a funding settlement from the government of £6.6 billion on top of the extra £3 billion received in the autumn Spending Review. The guidance clarifies that £1 billion of the Spending Review funding will be used for an Elective Recovery Fund, which will be in place from April, to be paid to health systems that achieve activity levels above set thresholds.
  • An additional funding settlement for the NHS for the second half of 2021-22 will be agreed once there is greater certainty around COVID-19 context and associated needs.
  • The guidance covers plans for the additional £1.5 billion funding for elective recovery, mental health and workforce development that was announced in the Spending Review, although we await further information on the breakdown of the mental health funding.
  • Additional funds for maternity services, breast cancer screening and general practice capacity.

Workforce capacity and recovery

  • To allow staff to rest and recover, trusts are encouraged to allow staff to carry over all unused annual leave and offer flexibility for staff to take or buy back unused leave, and system financial performance assessment excludes higher accruals for annual leave in 2020/21.
  • There is a roll out of 40 mental health hubs and an ask to local systems to maintain all clinically appropriate beneficial changes made to support staff through COVID-19, including staff wellbeing hubs.
  • Hospitals are being encouraged to develop their local workforce supply and to work collaboratively to increase supply and support economic recovery. 
  • Systems are expected to review and refresh their people plans to reflect the progress made in 2020/21, as well as to show greater progress on equality, diversity and inclusion, and progress on compassionate and inclusive cultures.
  • Systems are expected to develop and deliver a local workforce supply plan with a focus on both recruitment and retention, and support the recovery of the education and training pipeline. And on mental health, ensure this delivers the scale of the workforce growth required to meet the ambitions of the NHS Long Term Plan.

Continuing the vaccination programme and ongoing COVID-19 demands

  • The guidance re-emphasises the focus on offering a first dose of COVID-19 vaccine to all adults by the end of July 2021.
  • General practice will retain an important role in the COVID-19 vaccination programme, with PCN groupings having the option to vaccinate cohorts 10 to 12.
  • Systems will need to consider preparations for a COVID-19 revaccination programme from autumn, with high uptake ambitions for seasonal flu vaccination, alongside the possibility of COVID-19 vaccination of children, pending authorisation recommendations from the Joint Committee on Vaccination and Immunisation (JCVI).
  • PCNs will also have an important ongoing role in response to the pandemic that will involve the continued use of virtual care and proactive care at home.
  • There is commitment to continue national funding to maintain the dedicated post-COVID assessment clinics.

Elective and cancer care recovery

  • Inpatient/day case activity is expected to reach 70 per cent of 'normal' level by April, increasing to 80 per cent in May, 85 per cent in June and 85 per cent July-September.
  • This is set against a baseline of elective activity delivered in 2019/20, allowing for available funding, workforce recovery and negative productivity impacts of the pandemic through 2021/22. Baselines will be set nationally and performance measured at system level.
  • There will be no penalties for underperforming against these targets, but t rusts will be able to access incentives for overperforming.
  • Systems are asked to recover elective activity in a way that takes full advantage of elective high-impact changes and transformation opportunities.
  • Cancer services are expected to be restored to full operation, including reducing the number of people waiting for longer than 62 days to pre-COVID-19 levels and meeting the increased level of referrals and treatment required to address the shortfall in number of first treatments by March 2022.
  • Trusts are expected to deliver improvements in maternity care, including responding to the recommendations of the Ockenden review.
  • CCGs must continue to meet the MHIS. The £500 million of additional mental health funding announced at the Spending Review must be used to help with progress against NHS Long Term Plan goals and aid recovery of services from COVID-19, and cannot be used to meet the MHIS.

Expanding primary care capacity

  • There is continued commitment to increase real terms expenditure on primary and community health services to improve prevention and keep people out of hospital. This includes supporting access; implementing population health management and personalised care; and transforming community services.
  • Systems should prioritise local investment and support PCN development and integration with community-based services, specifically to achieve their share of 15,500 FTE by the end of the financial year and expand the number of GPs towards the 6,000 target.
  • National funding for general practice capacity also continues, with an additional £120 million in first half of the year, tapering as COVID-19 pressures decrease.
  • The guidance places a renewed focus on addressing health inequalities based on local needs, underpinned by data analysis and long-term condition management.
  • Systems are asked to develop robust plans for the prevention of ill-health, led by a nominated senior responsible officer, covering both primary and secondary NHS Long Term Plan prevention deliverables.

Transforming community and urgent and emergency care

  • With national transformation funding and an increase in primary and community care, systems are asked to set out plans to accelerate rollout of the two-hour crisis community health response at home to provide national cover (8am-8pm, seven days) by April 2022. Additional transformation funding will be released subject to those plans.
  • From July, NHSEI has also committed to continue to fund the first six weeks of care after discharge during the first quarter and first four weeks.
  • Systems are asked to continue to progress the work already underway through the NHS 111 First and Same Day Emergency Care programmes.

System working

  • Supplementary guidance is provided on developing ICS infrastructure, including on the requirements for undertaking planning and financial allocations on a system basis.
  • ICSs will be asked to set out, by the end of Q1, the delivery and governance arrangements that will support delivery of the NHS priorities set out in the guidance. These must be set out in a memorandum of understanding and agreed with regional NHSEI teams.
  • Systems are asked to develop their own set of local health and care priorities that reflect the needs of their population.
  • Systems must develop the underpinning digital and data capability to support population-based approaches.

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